Abstract

Background The improvement of community tolerance of people with
mental illnessis important for their integration. Little is known about the
knowledge of and attitude to mental illness in sub-Saharan Africa.

Aims To determine the knowledge and attitudes of a representative
community sample in Nigeria.

Method Amultistage, clustered sample of household respondents was
studied in three states in the Yoruba-speaking parts of Nigeria (representing
22% of the national population). A total of 2040 individuals participated
(responserate 74.2%).

Results Poor knowledge of causation was common.Negative views of
mental illness were widespread, with as many as 96.5% (s.d.=0.5) believing
that people with mental illness are dangerous because of their violent
behaviour. Most would not tolerate even basic social contacts with a mentally
ill person: 82.7% (s.e.=1.3) would be afraid to have a conversation with a
mentally ill person and only 16.9% (s.e.=0.9) would consider marrying one.
Socio-demographic predictors of both poor knowledge and intolerant attitude
were generally very few.

Conclusions There is widespread stigmatisation of mental illness in
the Nigerian community. Negative attitudes to mental illness may be fuelled by
notions of causation that suggest that affected people are in some way
responsible for their illness, and by fear.

Mental illness often constitutes a double jeopardy for those affected
because of stigmatisation by members of the community
(Corrigan & Watson, 2002).
Studies conducted in North America and western Europe suggest that stigma is a
major problem in the community (Taylor & Dear, 1980; Brockington
et al, 1993; Huxley,
1993; Jorm et al,
1999; Crisp et al,
2000). Negative views such as those implying that people with
mental illness are irresponsible and therefore incapable of making their own
decisions, or are dangerous and are to be feared, are widespread. Since
negative beliefs often lead to discrimination, there is little wonder that
studies have also shown that people with mental health problems living in the
community experience rampant harassment
(Kelly & McKenna, 1997;
Berzins et al, 2003).
Some studies conducted in Africa have suggested that the experience of stigma
by people with mental illness may be common
(Awaritefe & Ebie, 1975;
Shibre et al, 2001),
but there is no information on how widespread negative attitudes to mental
illness may be in the community. As noted by Corrigan & Watson
(2002), it is unclear whether
the lack of empirical data partly explains the speculation that stigmatisation
of mental illness may be less common among Africans
(Fabrega, 1991).

METHOD

Sample characteristics

The survey was conducted in three Yoruba-speaking states in south-western
Nigeria (Ogun, Oyo and Osun) between March and August 2002. The survey on
stigma was a segment of a much larger survey of mental disorders in the
community (the Nigeria Survey of Mental Health and Well-being) and was
administered by trained lay interviewers from the Department of Psychiatry,
University of Ibadan. Both studies were approved by the University of Ibadan
and University College Hospital joint ethics committee.

The study was based on a stratified, multistage clustered probability
sample of household residents aged 18 years or older in the selected states.
First, stratification was based on states (three categories) and size of the
primary stage units, which were the local government areas (two categories).
The second stage was to select two primary stage units per stratum, with
probability of selection proportional to size. The third stage was the random
selection of four enumeration areas from each local government area; these are
geographical units demarcated by the National Population Commission, each
consisting of about 60–80 household units. We enumerated the households
in each selected area and randomly selected the number of households required
to meet our desired sample size. One resident aged 18 years or over was
approached for participation in each selected household. We used the Kish
method to identify the potential respondent
(Kish, 1995) and no
replacement was made for refusals. A total of 2040 persons participated in the
survey on stigma, representing a response rate of 74.2%. The results presented
here have been weighed to reflect the within-household probability of
selection and to incorporate a post-stratification adjustment such that the
sample is representative of the age by gender distribution of the projected
population of Nigeria in 2000.

Income was categorised into four groups: ‘low’ (defined as less
than or equal to median or the pre-tax income per household), ‘low
average’ (greater than ‘low’ up to twice the median value), ‘
high average’ (greater than ‘low average’ up to three
times median value) and ‘high’ (greater than ‘high
average’). Residence was classified as rural (fewer than 12 000
households), semi-urban (12 000–20 000 households per local government
area) and urban (more than 20 000 households).

Assessment

A modified version of the questionnaire developed for the World Psychiatric
Association Programme to Reduce Stigma and Discrimination Because of
Schizophrenia was used (Stuart &
Arborleda-Florez, 2001; World
Psychiatric Association, 2002). The questionnaire is focused
mainly on knowledge of and attitude to schizophrenia. It was modified largely
to take account of the focus of this survey, which was on mental illness
rather than schizophrenia. Thus, in addition to substituting the term ‘
mental illness’ for ‘schizophrenia’, specific items
relating to the symptoms of schizophrenia were deleted. The questionnaire was
translated into Yoruba by a panel of four bilingual mental health research
workers using the iterative back-translation method. In the translation,
particular care was made to convey a broad idea of ‘mental
illness’ (arun opolo), differentiating it from psychosis
(iwin or were) and mental retardation (ode or
odoyo).

Analysis

Simple cross-tabulations were used to calculate proportions and their
distributions in different groups. To take account of the sampling procedure,
with clustering and weighting of cases, standard errors of proportions were
estimated with the jackknife method implemented in the STATA software
(StataCorp, 2001). Statistical
significance was evaluated at the 0.5 level and was based on two-sided
design-based tests.

RESULTS

Table 1 shows the
socio-demographic attributes of the sample. In keeping with the demographic
and economic profile of Nigeria, the sample was predominantly young and most
came from low or low average income households. The population of Nigeria is
predominantly rural, but the south-western area where the study was conducted
is more urban than the rest of the country and this is reflected in the
table.

Most respondents expressed the view that substance misuse (alcohol or
drugs, but mainly the latter) could result in mental illness
(Table 2). The next most
commonly endorsed cause of mental illness was a belief that it could be due to
possession by evil spirits. Following this, trauma, stress and heredity were
about equally ascribed as possible causes. Only about one in ten respondents
believed that biological factors or brain disease could be the cause of mental
illness. Confirming a stronger belief in supernatural causation, over 9%
thought mental illness could result from punishment from God, whereas only
about 6% thought poverty could cause mental illness.

The views about mental illness were generally negative
(Table 3). People with mental
illness were believed to be mentally retarded, to be a public nuisance and to
be dangerous. Less than half of the respondents believed that such people
could be treated outside hospital and only about one-quarter thought they
could work in regular jobs. Poor knowledge about mental illness seemed to
pervade all segments of the community: no consistent association was observed
between the predominantly negative views of mental illness on the one hand and
gender, age, education, income or residence on the other hand.

Table 4 shows that most
respondents were unwilling to have social interactions with someone with
mental illness. Most would be afraid to have a conversation and would be
disturbed to work with a person with mental illness. Only a few would be
willing to maintain a friendship and fewer still would consider marrying such
a person. There were also inconsistent associations of socio-demographic
attributes with negative attitudes to mental illness. As shown in
Table 4, apart from evidence of
a somewhat more liberal attitude of men and those residing in urban areas,
negative attitude to mental illness seems to be highly prevalent across many
different groups in the community.

DISCUSSION

To our knowledge, this is the first large-scale study of knowledge of and
attitudes towards mental illness in sub-Saharan Africa. Previous studies have
either been on a much smaller scale
(Awaritefe & Ebie, 1975;
Odejide & Olatawura,
1979), or have examined the perception of stigma by relatives of
people with mental illness (Shibre et
al, 2001) or the views of mental illness among special groups
(Binitie, 1970). Large-scale
community studies have been lacking. Such studies are of obvious importance
for any policy aimed at promoting better knowledge and tolerance of mental
illness by the public.

Caveats in interpreting the findings

In interpreting the results of the survey, cognisance should be taken of
its limitations. Even though the sample was selected to be representative of
the adult population of the Yoruba, who make up about 22% of the Nigerian
population, the views expressed may not necessarily reflect the views of the
other ethnic groups in the country. Nigeria is a culturally diverse country
and its various parts are dissimilar in their access to mental health services
(Ayonrinde et al,
2004), both of which factors may affect views about and attitude
to mental illness. Nevertheless, a few studies conducted among other ethnic
groups in Nigeria, albeit on a much smaller scale, suggest that the findings
here with regard to widespread poor knowledge of and attitude towards mental
illness may not be peculiar to the Yoruba ethnic group
(Binitie, 1970;
Awaritefe & Ebie, 1975).
Also, we have focused on mental illness generally, not on specific mental
disorders. In answering questions about mental illness, respondents might have
done so with a mind-set on a particular group of mental disorders, probably
psychotic disorders, even though our translation sought to capture the
specific focus of our interest on mental illness. Although this might have
biased their responses in one direction, it would still be remarkable if the
public view of what constitutes mental illness was a narrow one.

Causes of mental illness

The common views about what causes mental illness provide a basis for
setting other findings of our study in context. This is because views about
causation are strongly associated with stigmatising attitudes to mental
illness (Bhugra, 1989;
Hayward & Bright, 1997;
Haghighat, 2001). Our results
suggest that knowledge about mental illness is very poor in the Nigerian
community. The widespread belief that misuse of drugs is the cause of mental
illness may be regarded as good, in view of its possible restraining effect on
the use of illicit or psychoactive substances. However, since this is only
true for a very limited number of mental disorders, and since the public often
views the misuse of substances as a moral failing, this belief may translate
to a notion of mental illness as being self-inflicted. Such a view is more
likely to elicit condemnation rather than understanding or sympathy
(Weiner et al, 1988).
Other than alcohol, the most commonly used psychoactive substance in Nigeria
is cannabis. It is not uncommon for the public in Nigeria to make the
assumption that anyone using cannabis will have a mental illness or that
anyone with mental illness has used cannabis. Indeed, criminality is also
often included in the causal link. Thus, the use of cannabis is often seen as
implying a criminal predisposition and vice versa. Next in importance
in the list of possible causes of mental illness was a belief that it could be
due to possession by evil spirits, and this view was expressed by as many as a
third of our respondents. Also, almost one in ten in the community thought
mental illness might be a divine punishment. Such views, apart from further
implying that people with mental illness might in some way be deserving of
their lot, have important ramifications for the seeking of medical care by
persons affected. A supernatural view of the origin of mental illness may
imply that orthodox medical care would be futile and that help would be more
likely to be obtained from spiritualists and traditional healers. Indeed,
previous studies in Nigeria have suggested that care for mental illness is
most often sought from these providers
(Gureje et al, 1995)
and that a view about supernatural causation of mental illness is shared by
them. In proffering a ‘biological’ or ‘brain disease’
causation for mental illness, our respondents could have meant any of several
things. Poisoning, either deliberate or by eating dangerous herbs, is commonly
seen as a possible cause of mental illness. There is also a cultural
understanding that some emotionally trying traditional rites or rituals could
lead to mental illness in those who are not psychologically or physically
prepared. Childbirth can also upset the body mechanisms and lead to mental
health problems.

Views about mental illness

Negative views about individuals with mental illness were widely held. Less
than half of the respondents thought that people with mental illness could be
treated outside a hospital or other health facility, implying a belief that
community-based care is unlikely to be feasible and might even be dangerous
for the public. Only about a quarter thought that mentally ill people could
work in regular jobs. Most respondents thought that people with mental illness
were mentally retarded, were a public nuisance and were dangerous because of
their violent behaviour. These negative views were uniformly expressed by all
groups in our study, and there was no clear gender, age, educational or
economic correlate of poor knowledge. Negative views of mental illness have
been reported in some studies to be more common among the poorly educated,
those of low social class and persons aged 50 years and above
(Wolff et al, 1996);
our study did not identify such associations.

Attitudes towards people with mental illness

The negative views expressed by respondents were indicative of the degree
of tolerance they might have of people with mental illness. In particular,
views such as those of dangerousness and low intelligence have been found to
fuel community resentment of people with mental illness
(Hayward & Bright, 1997;
Corrigan & Watson, 2002).
Consequently, the attitudes of our survey respondents to people with mental
illness were not surprising. We found that most people in the community would
be afraid to have a conversation with someone known to have a mental illness
and only a few would consider such a person for friendship. The closer the
intimacy required for the interaction, the stronger the community’s
desire to keep a distance. Thus, less than 4% would consider marrying anyone
with mental illness. Here again, the associations with demographic or
residential features were very few indeed. Other than a somewhat more tolerant
attitude to people with mental illness shown by respondents residing in urban
areas and by men, there was no interpretable relationship between negative
attitudes to those who are mentally ill on the one hand, and age, education or
income on the other hand. Previous studies of selected groups in Nigeria have
suggested that negative attitude to mental illness may be less pervasive among
the well educated (Odejide &
Olatawura, 1979). Our findings suggest that the attitudes of such
groups do not reflect those of the community at large.

The universality of stigma

The findings of this survey do not support the claim that mental illness is
less stigmatised in developing countries
(Fabrega, 1991). Although
developing countries constitute a diverse group in terms of culture and social
norms, it is nevertheless true that our findings are in broad agreement with
the observations made by others working in places such as India and Ethiopia
(Thara & Srinivasan, 2000;
Shibre et al, 2001).
Indeed, as noted by Murthy
(2002), stigmatisation of
mental illness probably exists everywhere, even though the form and nature of
it may differ across cultures. Our observations suggest that poor knowledge of
the causes of mental illness, especially an attribution to supernatural
causation, as well as very negative views of persons with mental illness, may
indeed be more common in African communities than hitherto realised. Attitude
to mental illness is consequently characterised by intolerance of even basic
social contact with people known to have such illness. In a society in which
poor health facilities and poverty make the care of people with mental illness
a major burden for both patients and their families, the degree of stigma
experienced by individuals with mental illness suggest an unusual level of
illness-related burden.

The need for the development of a well-articulated mental health policy has
been identified for most African countries where none exists
(Gureje & Alem, 2000).
Findings such as those of our study suggest that a strong emphasis on public
education should be an important component of any such policy.

Clinical Implications and Limitations

CLINICAL IMPLICATIONS

In Nigeria, poor knowledge about the cause and nature of mental illness is
common in the community.

Negative attitudes to mental illness are widespread and may impair the
social integration of those with mental illness.

Public enlightenment to foster community acceptance of people who are
mentally ill is required for all sections of the community, especially for
residents of rural areas and the young.

LIMITATIONS

The study did not determine attitude to people with different mental
disorders. It is possible that attitude is not uniformly poor for all mental
disorders.

The study was conducted in one language group in Nigeria.Other ethnic
groups may have different views about and attitudes to mental illness.

The information was obtained through a self-report interview; self-report
of attitude and knowledge might have been influenced by a need to conform to
perceived cultural norms.

Jorm, A. F., Korten, A. E., Jacomb, P. A., et al
(1999) Attitudes towards people with a mental disorder: a
survey of the Australian public and health professionals.
Australian and New Zealand Journal of Psychiatry,
33, 77–
83.

Shibre, T., Negash, A., Kullgren, G., et al
(2001) Perception of stigma among the family members of
individuals with schizophrenia and major affective disorders in rural
Ethiopia. Social Psychiatry and Psychiatric
Epidemiology, 36, 299–
303.